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General NPI Number Information
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NPI Number | 1134290877
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Entity Type | Individual
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Provider Name | DR. MICHAEL LUCKETT
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Gender | Male
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | 4839 CAL SAG RD # 310
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City | CRESTWOOD
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State | IL
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Zip | 60418-4415
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Country | US
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Telephone | 708-597-9055
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Fax | 216-584-7062
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Provider Business Mailing Address
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Address Line | 4839 CAL SAG RD # 310
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City | CRESTWOOD
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State | IL
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Zip | 60418-4415
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Country | US
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Telephone | 708-597-9055
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Fax | 216-584-1062
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019019835
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019-019835
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License Number State | IL
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